Urinary incontinence in the female

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					Urinary incontinence in the female

1.   Definition              8.   Investigations
2.   Stress incontinence     9.   Management-
3.   Prevalence                  Genuine stress
4.   Pathophysiology              incontinence
5.   Causes                      Detrusor instability
6.   Clinical presentation
7.   Physical examination
Definitions

   Involuntary loss of urine which is
    objectively demonstrable & is a social or
    hygienic problem.
   Stress incontinence: Involuntary expulsion of
    urine under conditions of stress like rise of
    intra-abdominal pressure due to coughing,
    sneezing , laughing or lifting weights.
Prevalence

 Upto 57% in women 45-64 yrs.
 14% in general population.
 Common condition, but rarely life
  threatening
 Adverse effect on quality of life
 Embarrassment and anxiety.
Pathophysiology of stress
incontinence

1.   Intravesical         2.   Detrusor pressure
     pressure exceeds          excessively high i.
     urethral pressure         e. Detrusor
     because of                Instability or
     weakness of
     urethral sphincter        Hyper-reflexia of
     mechanism i.e.            Bladder.
     Genuine Stress
     Incontinence
Causes of urinary incontinence
1.   Genuine stress             2.   Detrusor instability
     incontinence- congenital
                                3.   Retention with overflow
     weakness of bladder             incontinence
     neck, denervation of
                                4.   Urogenital fistula
     sphincter mechanism
     of pelvic floor (during    5.   Temporary – UTI,
     delivery), estrogen             drugs-α-blockers.
     deficiency in              6.   Urethral diverticulum
     menopause etc.
Causes (contd…)

7.   Congenital abnormalities- ectopic ureter,
     bladder exstrophy etc.
8.   Functional /neurologic disorders- dementia,
     spinal lesions, space occupying lesions in
     brain etc.
Clinical presentation

   Stress incontinence-            Detail history- prolapse,
    most common.                     obstetric history,
   Associated features-             recurrent UTI, episodes
    urgency, frequency,              of retention etc.
    dysuria, urge                   H/O diabetes, drugs –
    incontinence, voiding            diuretics, α-blockers etc.
    difficulties- poor stream,      Neurological symptom
    straining, incomplete
    emptying.
Physical examination

   With full bladder in stress incontinence.
   Local- excoriation of vulval skin.
   Atrophic changes, cystocele, prolapse.
   Bladder neck elevation test(Marchetti test)- To
    see whether surgery will benefit or not.
   Mental state, developmental anomalies,
    neurological examination.
Investigations

      General                        Basic Urodynamics
i.     Urine-                    i.    Uroflowmetry- 15-
       (MSU)Routine/microsc            25ml/sec
       opy, c/s                  ii.   Cystometry-
ii.    Frequency/volume                differentiate betn GSI
       chart or urinary diary.         &DI- Intravesical
iii.   Pad test.                       pressure during filling ,
                                       if > 15cm water after
                                       250 ml DI
Investigations (contd…)

   Residual urine- <5oml.       Videocystourethrography
   First sensation of urge      Combines cystometry,
    ~250ml. If earlierurge       uroflowmetry &
    incontinence.                 radiological screening of
   Bladder capacity- 500-        bladder & urethra.
    600ml. If                    Most informative, but
    increasedneurologic          expensive/time
    disease.                      consuming.
Special investigations

   Metallic bead chain          USG- position &
    urethrocystogram              excursion of bladder
   Urethral pressure             neck.
    profilometry.                Electromyography of
   Cystourethroscopy.            pudendal nerve.
   Micturition cystography      Urethral electric
                                  conductance.
Management of GSI

    Conservative
a.   Kegel’s exercises of pelvic floor muscles.
b.   Wt. Reduction in obese patients.
c.   Treat chronic cough, UTI.
d.   Faradism- interrupted current to stimulate
     muscles & nerves.
e.   Drugs- Estrogen, α adrenergic agonists-
     phenylpropanolamine.
Management (contd..)

    Surgical
    90% cure rate.
    Elevate bladder neck & proximal urethra into
     intra-abdominal position, support the bladder
     neck.
a.   Anterior colporrhaphy with Kelly suture.
b.   Marshall-Marchetti-Krantz operation-
     suprapubic approach.
Surgical management (contd…)

c.   Burch colposuspension.
d.   Pereyra procedure.
e.   Sling procedures- secondary- Stamey, Raz
f.   Artificial sphincter implant.
g.   GAX-collagen- periurethral injection.
h.   Urinary diversion- Last.
Detrusor Instability

   Spontaneous or provoked detrusor
    contractions during the filling phase when the
    pt. Is attempting to inhibit micturition.
   Urgency, urge incontinence, enuresis,
    frequency.
   No specific clinical signs.
Management of DI

1.   Behavioral interventions.
2.   Drugs- most widely used- anticholinergic agents-
     oxybutynin, propantheline., calcium channel blocker-
     terodiline, Tricyclic antidepressant-imipramine,
     αadrenergic stimulants., estrogen, synthetic
     vasopressin.
3.   Denervation- phenol injection, bladder transection,
     vaginal denervation, sacral neurectomy.
4.   Cystoplasty- clam ileocystoplasty.